Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within the required 14-day timeframe for two residents. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, federally mandated MDS assessments must be submitted within 14 calendar days after the MDS Completion Date. However, the facility did not comply with this requirement for Residents 41 and 45. Resident 41 had a quarterly MDS assessment with an Assessment Reference Date of January 2, 2024, which was submitted with errors in Section A (Identification Information) and Section C (Cognitive Patterns) and was not corrected and resubmitted within the required timeframe. Resident 45 was admitted and later discharged from the facility, with a Discharge - Return Not Anticipated MDS assessment scheduled but not completed or submitted within 14 days of the MDS Completion Date. The MDS for Resident 45 remained unsubmitted until it was identified during an on-site survey. The facility's Registered Nurse Assessment Coordinator confirmed the failure to submit the MDS assessments within the required timeframe.